complex in nature and arise from etiologies that are
both intrinsic and extrinsic to the patient. 9 Although
many SSIs are potentially preventable, nearly half
are unavoidable using existing evidence-based strategies. 10 It is noteworthy that participation in the ACS
National Surgical Quality Improvement Program
(ACS NSQIP®) is related to a significant decline in
SSI rates. 11

Our study yielded several important findings.
First, it is apparent that several changes in perioperative services policies have been implemented in
many hospitals or health systems over the past year,
but their enforcement varies greatly. Another important finding in our study is that the overwhelming
majority of respondents ( 93 percent and 96 percent,
respectively) thought that the recent policy changes
would have no impact on wound infections or overall outcomes. More than 90 percent of respondents
either disagreed or strongly disagreed with specific
statements in support of the implementation of specific new restrictions to attire in the OR.

A majority of respondents believed that the new
changes in OR attire would either worsen (
approximately two-thirds of all respondents) or have no
effect (approximately one-third of all respondents)
on morale among surgeons, nurses, anesthesiologists,
and the team as a whole. In addition, 70 percent of
respondents reported that the comfort of the operating surgeon would be reduced—a significant finding,
given that more than 80 percent indicated that surgeon comfort is an important safety factor that could
negatively affect patient outcomes.

The survey suggests that the most common driv-ing force in creating new OR attire policies are visitsby regulatory agencies. These agencies require ORpersonnel to follow a nationally recognized set ofguidelines. However, when our team of surgicalleaders reviewed the guidelines for perioperativepractice—standards that are the foundation of mostnew OR attire policy changes—we were nearlyunanimous that the evidence cited does not supportthe AORN’s recommendations and that much of theevidence lacks scientific validity in the first place.

(See Figure 3, page 15.)

AORN guidelines: What is the evidence?

We carefully reviewed the literature used to develop
the AORN guidelines. As stated earlier in this article,
much of the evidence that formed the basis for the
AORN recommendations is “quasi-scientific,” and is
founded on the premise that health care workers and
their apparel lead to bacterial contamination in the OR.
It has been well documented that bacteria are found in
human hair, on surgical attire, and on shed skin cells
called squames. 12-14 Many of the cited studies looked at
colony-forming units (CFUs) produced by the dispersal
of bacteria through the air and the number of bacterial species that were found on scrubs, but to date, no
study has shown that the use of specific scrub type has
a direct effect on SSI. 15-17

Recommendations also were made to completely
cover arms with a long-sleeved jacket. This guideline
is also based on a theoretical risk of SSI due to squame
production from exposed skin. Interestingly, in 2007,
the U.K. Department of Health took the exact opposite
stance and implemented a “bare below the elbows”
policy, which was thought to reduce patient exposure
to bacteria by promoting better hand hygiene practices. 18 Again, none of the available evidence supports
either policy.

Other guidelines also lack supporting evidence.AORN recommends wearing street clothes whenoutside the hospital. This restriction emerged from astudy comparing bacterial contamination of clothingworn inside and outside the perioperative area, whichshowed no increased contamination levels. 19 Althoughthat study did not address surgical attire worn outsideof the hospital, AORN stated that this recommendationwas supported by “moderate evidence.”The restriction of briefcases and backpacks in theOR is based on data that demonstrated that those itemscan harbor bacteria despite the fact no data has shownthat these personal items contribute to the occurrence